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IMPLEMENTATION AND EVALUATION 85 Again, trade-offs are inevitable. For instance, "desktop" compendiums of guidelines will involve trade-offs among appealing formats, accessible language, and ready availability of many different guidelines. The importance of appealing, accessible presentations of guidelines for practitioners and patients is often underestimated (and the development of such presentations underfunded). Presentation is not merely a frill but an aspect of guidelines implementation that requires serious attention. Nonetheless, as for every other step described in this report, the development of effective formats will have to compete with other priorities and will involve learning over time about what works better. To help that learning occur, the Forum should allocate some of its limited resources (or seek assistance from outside sources) to evaluate the effectiveness of alternative formats and media. In the short-term, the Forum should encourage its expert panels or contractors to offer suggestions about layout and to produce, in addition to any format required by the Forum, an alternative document if the group judges that alternative to be superior. Dissemination Dissemination as it is used here means getting guidelines to the intended users, particularly when they are initially published, adopted, or updated. Dissemination may occur in several phases or waves (Kaluzny, 1990). The first step comes when the government or other sponsor of guidelines development begins to publicize the development of a new set of guidelines. Generally, this publicity involves enlisting the aid of other organizations such as medical specialty societies. Second, even without the sponsor's intervention, other partiesâincluding the news media, computer information systems, professional colleagues, and workplace health promotion programsâmay help spread information. As hospitals, HMOs, and other organizations decide that the guidelines should be adopted for internal use, they will communicate them to physicians, nurses, and others. Because many organizations are developing guidelines, the AHCPR and its Forum are considering the need for a clearinghouse function and their relation to it. The committee did not consider this role in depth but notes that the quality of guidelines needs to be considered in any clearinghouse activity. Wider dissemination of poor guidelines is not in the public interest. As described below, the focus of dissemination is on creating awareness and general understanding. Providing the practitioner with ongoing, routine access to information in an actual delivery setting is treated here as an administrative issue (as described in the next section). Legislatively and practically, the Forum's dissemination strategies will rely heavily on the capacities and preferences of private or quasi-public
IMPLEMENTATION AND EVALUATION 86 groups such as medical organizations, consumer groups, and peer review organizations (PROs). As a consequence, no matter how cooperative these organizations are, many specific dissemination decisions will lie beyond the substantial influence of the Forum. Recognizing this, the committee offers only a few observations that may help the Forum and others in thinking about dissemination and its limits. The themes of credibility and accountability are relevant to decisions about dissemination. For example, using the journals, conferences, and other communication vehicles of medical specialty groups is more likely to lend credibility to the guidelines than using a Forum press release or a PRO newsletter. The former approach may also provide more opportunity for "full disclosure," thereby enhancing the accountability of the process. Personal presentations by those involved in developing guidelines may likewise have more impact than publicity statements, but such presentations imply the availability of a cadre of well-prepared presenters. Trade-offs are inevitable. For example, a press release may be the quickest vehicle for bringing high-priority guidelines3 to public and practitioner attention, but this timeliness typically comes at the loss (at least in the short run) of important information for different parties and the loss of some credibility with practitioners. PRO and carrier announcements are likely to be a swift mechanism for bringing Medicare-relevant guidelines to the attention of the medical community, but they are far less likely to reach the general public. The credibility and completeness of the information made available through on- line computer data bases (for example, MEDLARS) will depend on a variety of specific decisions about content, the extent of material to be available, retrieval rules, and development and access costs. Some evidence on the NLM's Physician Data Query (PDQ) suggests that patients are as likely as physicians to use that computerized information system, a finding that, if true of other, similar data bases, could raise some questions about how to target and present information (L. Blankenbaker, comments during an AHCPR methodology workshop, Rockville, Md., May 30, 1990). Dissemination of guidelines by PROs in the form of review criteria may be particularly helpful in focusing practitioner attention on the groups covered by the guidelines and on the exceptions. The PRO path of dissemination may, in turn, create an early feedback loop for updating the guidelines or criteria when important omissions are identified. For 3 Such guidelines include those involving a dramatic change from previous guidelines or those involving information that, if quickly applied, could significantly affect mortality or morbidity (Moldover, 1990; Steinbrook and Lo, 1990; "Word of Spinal- Injury Drug Not Getting Out," Washington Post, 1990).
